Associations between Stroke Mortality and Weekend Working by Stroke Specialist Physicians and Registered Nurses: Prospective Multicentre Cohort Study
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{"title"=>"Associations between stroke mortality and weekend working by stroke specialist physicians and registered nurses: Prospective multicentre cohort study", "type"=>"journal", "authors"=>[{"first_name"=>"Benjamin D.", "last_name"=>"Bray", "scopus_author_id"=>"55565099000"}, {"first_name"=>"Salma", "last_name"=>"Ayis", "scopus_author_id"=>"6507513866"}, {"first_name"=>"James", "last_name"=>"Campbell", "scopus_author_id"=>"36136568500"}, {"first_name"=>"Geoffrey C.", "last_name"=>"Cloud", "scopus_author_id"=>"7006885675"}, {"first_name"=>"Martin", "last_name"=>"James", "scopus_author_id"=>"35784487400"}, {"first_name"=>"Alex", "last_name"=>"Hoffman", "scopus_author_id"=>"8653492700"}, {"first_name"=>"Pippa J.", "last_name"=>"Tyrrell", "scopus_author_id"=>"7005446590"}, {"first_name"=>"Charles D.A.", "last_name"=>"Wolfe", "scopus_author_id"=>"57200115541"}, {"first_name"=>"Anthony G.", "last_name"=>"Rudd", "scopus_author_id"=>"19337989900"}], "year"=>2015, "source"=>"PLoS Medicine", "identifiers"=>{"sgr"=>"84936113455", "doi"=>"10.1371/journal.pmed.1001705", "issn"=>"15491676", "pui"=>"605099215", "isbn"=>"1549-1676", "pmid"=>"25137386", "scopus"=>"2-s2.0-84936113455"}, "id"=>"f67109cc-3d16-3f62-bb9c-f6879f84aeef", "abstract"=>"BACKGROUND: Observational studies have reported higher mortality for patients admitted on weekends. It is not known whether this \"weekend effect\" is modified by clinical staffing levels on weekends. We aimed to test the hypotheses that rounds by stroke specialist physicians 7 d per week and the ratio of registered nurses to beds on weekends are associated with mortality after stroke.\\n\\nMETHODS AND FINDINGS: We conducted a prospective cohort study of 103 stroke units (SUs) in England. Data of 56,666 patients with stroke admitted between 1 June 2011 and 1 December 2012 were extracted from a national register of stroke care in England. SU characteristics and staffing levels were derived from cross-sectional survey. Cox proportional hazards models were used to estimate hazard ratios (HRs) of 30-d post-admission mortality, adjusting for case mix, organisational, staffing, and care quality variables. After adjusting for confounders, there was no significant difference in mortality risk for patients admitted to a stroke service with stroke specialist physician rounds fewer than 7 d per week (adjusted HR [aHR] 1.04, 95% CI 0.91-1.18) compared to patients admitted to a service with rounds 7 d per week. There was a dose-response relationship between weekend nurse/bed ratios and mortality risk, with the highest risk of death observed in stroke services with the lowest nurse/bed ratios. In multivariable analysis, patients admitted on a weekend to a SU with 1.5 nurses/ten beds had an estimated adjusted 30-d mortality risk of 15.2% (aHR 1.18, 95% CI 1.07-1.29) compared to 11.2% for patients admitted to a unit with 3.0 nurses/ten beds (aHR 0.85, 95% CI 0.77-0.93), equivalent to one excess death per 25 admissions. The main limitation is the risk of confounding from unmeasured characteristics of stroke services.\\n\\nCONCLUSIONS: Mortality outcomes after stroke are associated with the intensity of weekend staffing by registered nurses but not 7-d/wk ward rounds by stroke specialist physicians. The findings have implications for quality improvement and resource allocation in stroke care. Please see later in the article for the Editors' Summary.", "link"=>"http://www.mendeley.com/research/associations-between-stroke-mortality-weekend-working-stroke-specialist-physicians-registered-nurses", "reader_count"=>49, "reader_count_by_academic_status"=>{"Unspecified"=>1, "Professor > Associate Professor"=>2, "Librarian"=>1, "Researcher"=>13, "Student > Ph. D. Student"=>4, "Student > Postgraduate"=>1, "Other"=>4, "Student > Master"=>12, "Student > Bachelor"=>4, "Lecturer"=>2, "Lecturer > Senior Lecturer"=>3, "Professor"=>2}, "reader_count_by_user_role"=>{"Unspecified"=>1, "Professor > Associate Professor"=>2, "Librarian"=>1, "Researcher"=>13, "Student > Ph. D. Student"=>4, "Student > Postgraduate"=>1, "Other"=>4, "Student > Master"=>12, "Student > Bachelor"=>4, "Lecturer"=>2, "Lecturer > Senior Lecturer"=>3, "Professor"=>2}, "reader_count_by_subject_area"=>{"Unspecified"=>1, "Nursing and Health Professions"=>13, "Medicine and Dentistry"=>23, "Design"=>1, "Business, Management and Accounting"=>3, "Social Sciences"=>5, "Decision Sciences"=>1, "Economics, Econometrics and Finance"=>1, "Linguistics"=>1}, "reader_count_by_subdiscipline"=>{"Design"=>{"Design"=>1}, "Medicine and Dentistry"=>{"Medicine and Dentistry"=>23}, "Social Sciences"=>{"Social Sciences"=>5}, "Decision Sciences"=>{"Decision Sciences"=>1}, "Economics, Econometrics and Finance"=>{"Economics, Econometrics and Finance"=>1}, "Nursing and Health Professions"=>{"Nursing and Health Professions"=>13}, "Business, Management and Accounting"=>{"Business, Management and Accounting"=>3}, "Linguistics"=>{"Linguistics"=>1}, "Unspecified"=>{"Unspecified"=>1}}, "reader_count_by_country"=>{"Japan"=>1, "United Kingdom"=>2}, "group_count"=>5}

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  • {"files"=>["https://ndownloader.figshare.com/files/1642246"], "description"=>"<p>IQR, interquartile range; LACI, lacunar syndrome; PACI, partial anterior circulation syndrome; POCI, posterior circulation syndrome; TACI, total anterior circulation syndrome.</p>", "links"=>[], "tags"=>["stroke specialist physicians", "Prospective Multicentre Cohort Study BackgroundObservational studies", "mortality risk", "hr", "stroke specialist physician rounds", "103 stroke units", "stroke specialist physicians 7", "weekend", "estimate hazard ratios", "ci", "su", "stroke services.ConclusionsMortality outcomes", "1 June 2011", "care quality variables", "1 December 2012"], "article_id"=>1144960, "categories"=>["Biological Sciences"], "users"=>["Benjamin D. Bray", "Salma Ayis", "James Campbell", "Geoffrey C. Cloud", "Martin James", "Alex Hoffman", "Pippa J. Tyrrell", "Charles D. A. Wolfe", "Anthony G. Rudd"], "doi"=>"https://dx.doi.org/10.1371/journal.pmed.1001705.t004", "stats"=>{"downloads"=>4, "page_views"=>10, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Characteristics_of_patient_population_organisational_characteristics_of_stroke_units_process_measures_of_care_quality_and_crude_mortality_rate_by_weekend_nurse_bed_ratio_/1144960", "title"=>"Characteristics of patient population, organisational characteristics of stroke units, process measures of care quality, and crude mortality rate by weekend nurse/bed ratio.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2014-08-19 03:38:50"}
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  • {"files"=>["https://ndownloader.figshare.com/files/1642249"], "description"=>"<p>Patient case mix: age, sex, stroke type, consciousness level, hypoxia, independence in activities of daily living before stroke, arm weakness, leg weakness, dysphasia, hemianopia. Organisational characteristics: total number of SU beds, 24/7 on-site stroke thrombolysis service. Staffing: average number of registered nurses/ten beds on weekdays, average number of registered nurses/ten beds on weekends, average number of healthcare assistants/ten beds on weekends. Care quality: only in ICU, HDU, or SU in first 24 h, antiplatelet therapy within 24 h (if indicated), brain scan within 24 h of admission.</p>", "links"=>[], "tags"=>["stroke specialist physicians", "Prospective Multicentre Cohort Study BackgroundObservational studies", "mortality risk", "hr", "stroke specialist physician rounds", "103 stroke units", "stroke specialist physicians 7", "weekend", "estimate hazard ratios", "ci", "su", "stroke services.ConclusionsMortality outcomes", "1 June 2011", "care quality variables", "1 December 2012"], "article_id"=>1144963, "categories"=>["Biological Sciences"], "users"=>["Benjamin D. Bray", "Salma Ayis", "James Campbell", "Geoffrey C. Cloud", "Martin James", "Alex Hoffman", "Pippa J. Tyrrell", "Charles D. A. Wolfe", "Anthony G. Rudd"], "doi"=>"https://dx.doi.org/10.1371/journal.pmed.1001705.t003", "stats"=>{"downloads"=>1, "page_views"=>8, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Hazard_ratios_of_death_by_30_d_in_univariable_and_multivariable_models_/1144963", "title"=>"Hazard ratios of death by 30 d in univariable and multivariable models.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2014-08-19 03:38:50"}
  • {"files"=>["https://ndownloader.figshare.com/files/1642248"], "description"=>"<p>IQR, interquartile range; LACI, lacunar syndrome; PACI, partial anterior circulation syndrome; POCI, posterior circulation syndrome; TACI, total anterior circulation syndrome.</p>", "links"=>[], "tags"=>["stroke specialist physicians", "Prospective Multicentre Cohort Study BackgroundObservational studies", "mortality risk", "hr", "stroke specialist physician rounds", "103 stroke units", "stroke specialist physicians 7", "weekend", "estimate hazard ratios", "ci", "su", "stroke services.ConclusionsMortality outcomes", "1 June 2011", "care quality variables", "1 December 2012"], "article_id"=>1144962, "categories"=>["Biological Sciences"], "users"=>["Benjamin D. Bray", "Salma Ayis", "James Campbell", "Geoffrey C. Cloud", "Martin James", "Alex Hoffman", "Pippa J. Tyrrell", "Charles D. A. Wolfe", "Anthony G. Rudd"], "doi"=>"https://dx.doi.org/10.1371/journal.pmed.1001705.t002", "stats"=>{"downloads"=>2, "page_views"=>9, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Characteristics_of_patients_and_hospitals_in_SUs_with_stroke_specialist_physician_rounds_lt_7_d_wk_/1144962", "title"=>"Characteristics of patients and hospitals in SUs with stroke specialist physician rounds <7 d/wk.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2014-08-19 03:38:50"}
  • {"files"=>["https://ndownloader.figshare.com/files/1642233"], "description"=>"<p>The adjusted HR is the difference in hazard associated with admission on a weekend versus a weekday, by ratio of registered nurses per ten beds on a weekend. HRs adjusted for patient case mix, organisational characteristics, staffing, and care quality.</p>", "links"=>[], "tags"=>["stroke specialist physicians", "Prospective Multicentre Cohort Study BackgroundObservational studies", "mortality risk", "hr", "stroke specialist physician rounds", "103 stroke units", "stroke specialist physicians 7", "weekend", "estimate hazard ratios", "ci", "su", "stroke services.ConclusionsMortality outcomes", "1 June 2011", "care quality variables", "1 December 2012"], "article_id"=>1144956, "categories"=>["Biological Sciences"], "users"=>["Benjamin D. Bray", "Salma Ayis", "James Campbell", "Geoffrey C. Cloud", "Martin James", "Alex Hoffman", "Pippa J. Tyrrell", "Charles D. A. Wolfe", "Anthony G. Rudd"], "doi"=>"https://dx.doi.org/10.1371/journal.pmed.1001705.g004", "stats"=>{"downloads"=>7, "page_views"=>16, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Interaction_between_nursing_ratios_and_weekend_admission_/1144956", "title"=>"Interaction between nursing ratios and weekend admission.", "pos_in_sequence"=>0, "defined_type"=>1, "published_date"=>"2014-08-19 03:38:50"}
  • {"files"=>["https://ndownloader.figshare.com/files/1642230"], "description"=>"<p>Scatter plot of weekday nurses per ten beds versus weekend nurses per ten beds.</p>", "links"=>[], "tags"=>["stroke specialist physicians", "Prospective Multicentre Cohort Study BackgroundObservational studies", "mortality risk", "hr", "stroke specialist physician rounds", "103 stroke units", "stroke specialist physicians 7", "weekend", "estimate hazard ratios", "ci", "su", "stroke services.ConclusionsMortality outcomes", "1 June 2011", "care quality variables", "1 December 2012"], "article_id"=>1144953, "categories"=>["Biological Sciences"], "users"=>["Benjamin D. Bray", "Salma Ayis", "James Campbell", "Geoffrey C. Cloud", "Martin James", "Alex Hoffman", "Pippa J. Tyrrell", "Charles D. A. Wolfe", "Anthony G. Rudd"], "doi"=>"https://dx.doi.org/10.1371/journal.pmed.1001705.g001", "stats"=>{"downloads"=>2, "page_views"=>20, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Scatter_plot_of_weekday_nurses_per_ten_beds_versus_weekend_nurses_per_ten_beds_/1144953", "title"=>"Scatter plot of weekday nurses per ten beds versus weekend nurses per ten beds.", "pos_in_sequence"=>0, "defined_type"=>1, "published_date"=>"2014-08-19 03:38:50"}
  • {"files"=>["https://ndownloader.figshare.com/files/1642251"], "description"=>"<div><p>Background</p><p>Observational studies have reported higher mortality for patients admitted on weekends. It is not known whether this “weekend effect” is modified by clinical staffing levels on weekends. We aimed to test the hypotheses that rounds by stroke specialist physicians 7 d per week and the ratio of registered nurses to beds on weekends are associated with mortality after stroke.</p><p>Methods and Findings</p><p>We conducted a prospective cohort study of 103 stroke units (SUs) in England. Data of 56,666 patients with stroke admitted between 1 June 2011 and 1 December 2012 were extracted from a national register of stroke care in England. SU characteristics and staffing levels were derived from cross-sectional survey. Cox proportional hazards models were used to estimate hazard ratios (HRs) of 30-d post-admission mortality, adjusting for case mix, organisational, staffing, and care quality variables. After adjusting for confounders, there was no significant difference in mortality risk for patients admitted to a stroke service with stroke specialist physician rounds fewer than 7 d per week (adjusted HR [aHR] 1.04, 95% CI 0.91–1.18) compared to patients admitted to a service with rounds 7 d per week. There was a dose–response relationship between weekend nurse/bed ratios and mortality risk, with the highest risk of death observed in stroke services with the lowest nurse/bed ratios. In multivariable analysis, patients admitted on a weekend to a SU with 1.5 nurses/ten beds had an estimated adjusted 30-d mortality risk of 15.2% (aHR 1.18, 95% CI 1.07–1.29) compared to 11.2% for patients admitted to a unit with 3.0 nurses/ten beds (aHR 0.85, 95% CI 0.77–0.93), equivalent to one excess death per 25 admissions. The main limitation is the risk of confounding from unmeasured characteristics of stroke services.</p><p>Conclusions</p><p>Mortality outcomes after stroke are associated with the intensity of weekend staffing by registered nurses but not 7-d/wk ward rounds by stroke specialist physicians. The findings have implications for quality improvement and resource allocation in stroke care.</p><p><i>Please see later in the article for the Editors' Summary</i></p></div>", "links"=>[], "tags"=>["stroke specialist physicians", "Prospective Multicentre Cohort Study BackgroundObservational studies", "mortality risk", "hr", "stroke specialist physician rounds", "103 stroke units", "stroke specialist physicians 7", "weekend", "estimate hazard ratios", "ci", "su", "stroke services.ConclusionsMortality outcomes", "1 June 2011", "care quality variables", "1 December 2012"], "article_id"=>1144965, "categories"=>["Biological Sciences"], "users"=>["Benjamin D. Bray", "Salma Ayis", "James Campbell", "Geoffrey C. Cloud", "Martin James", "Alex Hoffman", "Pippa J. Tyrrell", "Charles D. A. Wolfe", "Anthony G. Rudd"], "doi"=>"https://dx.doi.org/10.1371/journal.pmed.1001705", "stats"=>{"downloads"=>1, "page_views"=>21, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Associations_between_Stroke_Mortality_and_Weekend_Working_by_Stroke_Specialist_Physicians_and_Registered_Nurses_Prospective_Multicentre_Cohort_Study_/1144965", "title"=>"Associations between Stroke Mortality and Weekend Working by Stroke Specialist Physicians and Registered Nurses: Prospective Multicentre Cohort Study", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2014-08-19 03:38:50"}
  • {"files"=>["https://ndownloader.figshare.com/files/1642250"], "description"=>"<p>IQR, interquartile range; LACI, lacunar syndrome; PACI, partial anterior circulation syndrome; POCI, posterior circulation syndrome; TACI, total anterior circulation syndrome.</p>", "links"=>[], "tags"=>["stroke specialist physicians", "Prospective Multicentre Cohort Study BackgroundObservational studies", "mortality risk", "hr", "stroke specialist physician rounds", "103 stroke units", "stroke specialist physicians 7", "weekend", "estimate hazard ratios", "ci", "su", "stroke services.ConclusionsMortality outcomes", "1 June 2011", "care quality variables", "1 December 2012"], "article_id"=>1144964, "categories"=>["Biological Sciences"], "users"=>["Benjamin D. Bray", "Salma Ayis", "James Campbell", "Geoffrey C. Cloud", "Martin James", "Alex Hoffman", "Pippa J. Tyrrell", "Charles D. A. Wolfe", "Anthony G. Rudd"], "doi"=>"https://dx.doi.org/10.1371/journal.pmed.1001705.t001", "stats"=>{"downloads"=>5, "page_views"=>14, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Characteristics_of_patient_population_organisational_characteristics_of_stroke_units_process_measures_of_care_quality_and_crude_mortality_rate_by_presence_of_physician_ward_rounds_7_d_wk_versus_lt_7_d_wk_/1144964", "title"=>"Characteristics of patient population, organisational characteristics of stroke units, process measures of care quality, and crude mortality rate by presence of physician ward rounds 7 d/wk versus <7 d/wk.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2014-08-19 03:38:50"}
  • {"files"=>["https://ndownloader.figshare.com/files/1642247"], "description"=>"<p>Patient case mix: age, sex, stroke type, consciousness level, hypoxia, independence in activities of daily living before stroke, arm weakness, leg weakness, dysphasia, hemianopia. Organisational characteristics: total number of SU beds, 24/7 on-site stroke thrombolysis service. Staffing: physician ward rounds 7 d/wk, number of healthcare assistants/ten beds on weekends. Care quality: only in ICU, HDU, or SU in first 24 h, antiplatelet therapy within 24 h (if indicated), brain scan within 24 h of admission.</p>", "links"=>[], "tags"=>["stroke specialist physicians", "Prospective Multicentre Cohort Study BackgroundObservational studies", "mortality risk", "hr", "stroke specialist physician rounds", "103 stroke units", "stroke specialist physicians 7", "weekend", "estimate hazard ratios", "ci", "su", "stroke services.ConclusionsMortality outcomes", "1 June 2011", "care quality variables", "1 December 2012"], "article_id"=>1144961, "categories"=>["Biological Sciences"], "users"=>["Benjamin D. Bray", "Salma Ayis", "James Campbell", "Geoffrey C. Cloud", "Martin James", "Alex Hoffman", "Pippa J. Tyrrell", "Charles D. A. Wolfe", "Anthony G. Rudd"], "doi"=>"https://dx.doi.org/10.1371/journal.pmed.1001705.t005", "stats"=>{"downloads"=>1, "page_views"=>18, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Hazard_ratios_of_death_by_30_d_in_univariable_and_multivariable_models_/1144961", "title"=>"Hazard ratios of death by 30 d in univariable and multivariable models.", "pos_in_sequence"=>0, "defined_type"=>3, "published_date"=>"2014-08-19 03:38:50"}
  • {"files"=>["https://ndownloader.figshare.com/files/1642245"], "description"=>"<p>Unadjusted hazard ratio of 30-d mortality of patients admitted on weekends, by ratio of registered nurses per ten beds on the weekend.</p>", "links"=>[], "tags"=>["stroke specialist physicians", "Prospective Multicentre Cohort Study BackgroundObservational studies", "mortality risk", "hr", "stroke specialist physician rounds", "103 stroke units", "stroke specialist physicians 7", "weekend", "estimate hazard ratios", "ci", "su", "stroke services.ConclusionsMortality outcomes", "1 June 2011", "care quality variables", "1 December 2012"], "article_id"=>1144959, "categories"=>["Biological Sciences"], "users"=>["Benjamin D. Bray", "Salma Ayis", "James Campbell", "Geoffrey C. Cloud", "Martin James", "Alex Hoffman", "Pippa J. Tyrrell", "Charles D. A. Wolfe", "Anthony G. Rudd"], "doi"=>"https://dx.doi.org/10.1371/journal.pmed.1001705.g006", "stats"=>{"downloads"=>2, "page_views"=>24, "likes"=>0}, "figshare_url"=>"https://figshare.com/articles/_Unadjusted_hazard_ratio_of_30_d_mortality_of_patients_admitted_on_weekends_by_ratio_of_registered_nurses_per_ten_beds_on_the_weekend_/1144959", "title"=>"Unadjusted hazard ratio of 30-d mortality of patients admitted on weekends, by ratio of registered nurses per ten beds on the weekend.", "pos_in_sequence"=>0, "defined_type"=>1, "published_date"=>"2014-08-19 03:38:50"}

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Relative Metric

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